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Australia Day Awards - Nomination Form

Before submitting a nomination, please read the Australian Day Guidelines and selection criteria on the last pages of this form.

The Awards are provided by the Australia Day Council NT and are administered by Local Government Authorities. Each Local Government area will be responsible for the criteria for the presentation of the Award.
Nomination for

Details of the person being nominated

Please include detailed information and address the specific award nomination criteria including:
  • Any volunteer works.
  • Community activities.
  • Membership of community groups, service clubs, sporting organisations.
  • The period covered by the nomination.
  • Why nominee should they receive an award
Please detail further information including the following, where appropriate:
  • How the nominee’s efforts benefited others in that field.
  • The nominee’s level of community engagement in the activity.
  • The level of excellence that the person has demonstrated in their chose field.
  • The beneficial impacts to the broader community.
  • How the event benefits the community.
  • Approximate number of attendees.
  • How the proceeds were allocated.
  • Detail one successful aspect of the activity?
  • How the activity creates public interest.
  • What the activity objectives were and how were they achieved?
Maximum 5 files.
5 MB limit.
Allowed types: gif, jpg, png, bmp, eps, tif, pict, psd, txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mov, mp3, ogg.

Nominator contact details

Sign above

Referees / Letter of Support

Referees or Letters of Support
Nominations should include at least two letters of support or referees from different perspectives of the applicant’s achievements. Referees may be contacted by the selection committee as part of the decision-making process and at least one referee should have a good knowledge of the nominee’s key area of activity.

Referee 1

Referee 2

Maximum 2 files.
5 MB limit.
Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods.